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TMSIS Dataguide Medicaid.gov
Version 3.38.0

MCR-56P-001-1

Data Quality Measure
Last updated

Key Information

Measure Name % of claims for which Patient Status is NOT "still a patient" but are missing Discharge Date, by Plan ID
File Type CIP
Measure ID MCR-56P-001-1
Measure Type Claims Percentage
Content area MCR
Associated Measure MCR-56R-001-1

Validation

Validation Type Inferential

Measure Priority

Measure Priority N/A
Focus Area N/A
Category N/A

Claim Information

Claim Type Medicaid,Enc
Adjustment Type All Adjustment Types
Crossover Type All Indicators

Thresholds

Minimum 0
Maximum 0.05
TA Minimun
TA Maximum
Longitudinal Threshold N/A
For TA
(for including in compliance training) 		No
For TA
(Longitudinal) 		No

Data Elements

DD Data Element DISCHARGE-DATE • PATIENT-STATUS
DD Data Element Number CIP096 • CIP199

Annotation For each unique Plan ID, calculate the percentage of claims that are Medicaid Encounter: original and adjustment, and paid where patient status is not "Still a patient" and the discharge date is missing
Specification STEP 1: Enrolled on the last day of DQ report month

Define the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:

1. ENROLLMENT-EFF-DATE <= last day of the DQ report month

2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing

3. MSIS-IDENTIFICATION-NUM is not missing



STEP 2: Managed care enrollment on the last day of DQ report month

Of the MSIS-IDs that meet the criteria from STEP 1, further refine the population using segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:

1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month

2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missing

OR

1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing

2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missing



STEP 3: Managed care plans on the last day of DQ report month

Define the managed care plan population from segment MANAGED-CARE-MAIN-MCR00002 by keeping active records that satisfy the following criteria:

1. MANAGED-CARE-MAIN-REC-EFF-DATE <= last day of the reporting month

2. MANAGED-CARE-MAIN-REC-END-DATE >= last day of the reporting month OR missing



STEP 4: Active non-duplicate IP records during DQ report month

Define the IP records universe at the header level that satisfy the following criteria:

1. Reporting Period for the filename = DQ report month

2. CLAIM-STATUS-CATEGORY is not equal to "F2" or is missing

3. CLAIM-DENIED-INDICATOR is not equal to "0" or is missing

4. TYPE-OF-CLAIM is not equal to "Z" or is missing

5. CLAIM-STATUS is not equal to ("26","026","87","087","542","585","654") or is missing

6. No Header Duplicates: Duplicates are dropped at the header-level, if the following four data elements are the same: ICN-ORIG, ICN-ADJ, ADJUDICATION-DATE, and ADJUSTMENT-IND.



STEP 5: Medicaid and S-CHIP Capitation Payment and Encounter: Paid Claims

Of the claims that meet the criteria from STEP 4, further restrict them by the following criteria:

1. TYPE-OF-CLAIM = (“2” or "3" or “B” or "C")



STEP 6: Define Plan_Id

Define Plan_Id as a unique list of: MANAGED-CARE-PLAN-ID from the EL file that meet the constraints in STEP 2, STATE-PLAN-ID-NUM from the MCR file that meet the constraints in STEP 3, and PLAN-ID-NUMBER from the claims files that meet the constraints in STEP 5. Also, define a blank Plan_Id for missing.



STEP 7: Medicaid Encounter: Original and Adjustment, Paid Claims

Of the claims that meet the criteria from STEP 1, further restrict them by the following criteria:

1. TYPE-OF-CLAIM = "3"



STEP 8: Patient status is not "Still a Patient"

Of the claims that meet the criteria from STEP 7, further restrict them by the following criteria:

1. PATIENT-STATUS is not equal to "30"

2. PATIENT-STATUS is not missing



STEP 9: Missing discharge date

Of the claims from STEP 8, select records where:

1. DISCHARGE-DATE is missing



STEP 10: Calculate the percentage for the measure

Divide the count of claims from STEP 9 by the count of claims from STEP 8



STEP 11: Repeat for each Plan_Id

REPEAT STEPS 7-10 for each Plan_Id identified in STEP 6